[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-detail-307672-en":3,"doc-seo-307672-105":29,"detail-sidebar-cat-1-en-105":97},{"code":4,"msg":5,"data":6},0,"success",{"doc_id":7,"user_id":8,"nickname":9,"user_avatar":10,"doc_module":11,"category_id":12,"category_name":13,"doc_title":14,"doc_description":15,"doc_content":16,"file_id":17,"file_url":18,"file_type":19,"file_size":20,"view_count":21,"is_deleted":4,"is_public":11,"is_downloadable":11,"audit_status":11,"page_count":11,"language":22,"language_code":23,"site_id":24,"html_lang":23,"table_of_contents":25,"faqs":26,"seo_title":27,"seo_description":15,"update_tm":28,"read_time":4},307672,13056703019404,"Miles","https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0",1,17,"Forms","Texas Child Neurology - Medication Refill Request Form","This document provides the official Medication Refill Request Form for patients of Texas Child Neurology, PLLC. It outlines necessary patient and medication details, including specific requirements for identifying extended-release medications. The form details delivery options such as pharmacy pickup or mail service, while explicitly noting Texas legal restrictions regarding ADD/ADHD prescriptions. It also establishes processing timelines, a service fee structure for specific medication requests, and payment authorization procedures for credit card processing.","Texas Child Neurology, PLLC  \nMedication Refill request Form  \nParents: This form can be mailed or faxed directly to us at:  \n972-769-0035  \nPhysician:   Date:   Patient Name:   Date of Birth:  Address:   Phone Number  Medication: * Please note if the medication contains the letters XR or ER for the extended release medications* Dosage:  Directions:   \n 30day supply  90day (3-30day scripts) for pharmacy  90day for mail order  \n Mail Pick Up  \n Please note that ADD/ADHD medications CAN NOT be called or faxed into the pharmacy per Texas Laws. They must be picked up or mailed.  \n****Please note that refills can take up to 48 hours to process so please plan accordingly. There is also a $10.00 charge for all ADD/ADHD medication refills obtained outside of a doctor’s visit. All ADD/ADHD prescriptions also have an expiration date of twenty one  \n(21) days after the date on the script. Please call your pharmacy and have them fax us arefill request on all non-ADD/ADHD medications. Please note that past due balancesand missed appointments may delay your refills. Thank you.  \n MasterCard  Visa  \nCredit Card Information:  \nCard \\#   Exp Date:  Name on the Card   \nBilling address on card  Please indicate if you would like for TCN to keep the Credit Card information on file for future medication refill request only.  YES  NO  \nSignature *I authorize Texas Child Neurology to bill my credit card $10.00 for the triplicate, and if applicable, any past  \ndue balance. * Revised 3-12  \nTexas Child Neurology 1708 Coit Road \\# 150 Plano, TX 75075","cbCainZVOQrkEIyh","https://ap.wps.com/l/cbCainZVOQrkEIyh","pdf",38124,10,"English","en",105,"# Patient and Medication Information\n## Refill Delivery Preferences\n# ADD/ADHD Medication Policy\n## Processing and Fees\n# Credit Card Payment Authorization","[{\"question\":\"How long does it typically take to process a medication refill request?\",\"answer\":\"Refill requests can take up to 48 hours to process, so patients are advised to plan accordingly.\"},{\"question\":\"Are there specific requirements for ADD/ADHD medication refills?\",\"answer\":\"Yes, ADD/ADHD medications cannot be called or faxed into a pharmacy per Texas law; they must be picked up or mailed. Additionally, there is a $10.00 charge for these refills if obtained outside of a doctor’s visit, and the prescriptions expire 21 days after the issue date.\"},{\"question\":\"What payment information is required if paying the $10.00 fee?\",\"answer\":\"Patients must provide the credit card number, expiration date, name on the card, and billing address, and specify whether they authorize Texas Child Neurology to keep this information on file for future requests.\"}]","Texas Child Neurology - Medication Refill Request Form | PDF",1789853051,{"code":4,"msg":30,"data":31},"ok",{"site_id":24,"language":23,"slug":32,"title":14,"keywords":33,"description":15,"schema_data":34,"social_meta":91,"head_meta":93,"extra_data":95,"updated_unix":96},"texas-child-neurology-medication-refill-request-form","",{"@graph":35,"@context":90},[36,53,73],{"@type":37,"itemListElement":38},"BreadcrumbList",[39,43,47,50],{"item":40,"name":41,"@type":42,"position":11},"https://docshare.wps.com","Home","ListItem",{"item":44,"name":45,"@type":42,"position":46},"https://docshare.wps.com/template/","Template",2,{"item":48,"name":13,"@type":42,"position":49},"https://docshare.wps.com/template/forms/",3,{"item":51,"name":14,"@type":42,"position":52},"https://docshare.wps.com/template/texas-child-neurology-medication-refill-request-form/307672/",4,{"url":51,"name":14,"@type":54,"image":55,"author":60,"headline":14,"publisher":62,"fileFormat":65,"inLanguage":23,"description":15,"dateModified":66,"datePublished":67,"encodingFormat":65,"isAccessibleForFree":68,"interactionStatistic":69},"DigitalDocument",{"url":56,"@type":57,"width":58,"height":59},"https://docshare.wps.com/thumbnails/texas-child-neurology-medication-refill-request-form/307672.png","ImageObject",442,249,{"name":9,"@type":61},"Person",{"url":40,"name":63,"@type":64},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":70,"interactionType":71,"userInteractionCount":21},"InteractionCounter",{"@type":72},"ViewAction",{"@type":74,"mainEntity":75},"FAQPage",[76,82,86],{"name":77,"@type":78,"acceptedAnswer":79},"How long does it typically take to process a medication refill request?","Question",{"text":80,"@type":81},"Refill requests can take up to 48 hours to process, so patients are advised to plan accordingly.","Answer",{"name":83,"@type":78,"acceptedAnswer":84},"Are there specific requirements for ADD/ADHD medication refills?",{"text":85,"@type":81},"Yes, ADD/ADHD medications cannot be called or faxed into a pharmacy per Texas law; they must be picked up or mailed. 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